How to Apply for a Constraint-Induced Movement Therapy (CIMT) Program

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1 How to Apply for a Constraint-Induced Movement Therapy (CIMT) Program Constraint-Induced Movement Therapy (CI Therapy, or CIMT): Two Programs There are two programs offered it the Taub Therapy Clinic for CIMT. You may apply for one or both of these programs although treatment for these programs is not combined but given three months apart so that each patient has a chance to focus on using a specific limb in treatment. These two programs are as follows: Arm/ Hand CI Therapy Program Leg/ Walking CI Therapy Program Who is a candidate for Constraint-Induced Movement Therapy (CI therapy, or CIMT)? Most candidates for CI therapy have already completed their traditional rehabilitation. However, many continue to suffer from the chronic effects of a stroke, traumatic brain injury, or other neurological injury. For appropriate candidates, CI therapy has been found to be effective no matter how long ago the stroke or injury occurred. CI therapy has specific requirements for acceptance into the Arm/ Hand CI Therapy Program and / or the Leg/ Walking CI Therapy Program. Your application form and video are reviewed by our therapists to see if you or your loved one meets criteria to receive treatment at this clinic. What kind of time commitment is involved? As the patient, you will play an integral role in your own success at the Taub Therapy Clinic. One of the reasons CI therapy is more effective than other therapy programs is because of its intensity. Depending upon each patient s condition, CI therapy may consist of sessions 3 ½ to 4 hours each day, 5 days per week for 2 to 3 weeks. Patients must also complete tasks and/or exercises independently or with the assistance of companion in the evenings and on weekends. After completing their CI therapy program, patients are given an individualized program to follow at home. The patient is also asked to complete four self-evaluations to help the clinic track progress and to make recommendations for improving the home program. How do I apply? Candidates must submit a written application to the Taub Therapy Clinic. There are two ways to send your application to the Taub Therapy Clinic including: 1. Download and print the pdf version of the application form and return it with the required videos by Taubclinic@uabmc.edu, fax (205) , or by mail (address below). 2. Request an application form by calling TAUB (8282) and return it with the required videos by Taubclinic@uabmc.edu, fax (205) , or by mail (address below). Mailing Address: Taub Therapy Clinic Spain Rehabilitation Center Room R th Avenue South Birmingham, AL 35249

2 TAUB THERAPY CLINIC Constraint Induced Movement Therapy Date: PATIENT INFORMATION FORM WITH INSTRUCTION FOR FILMING *Please visit our website to find instructions for filming the movement of your arm and hand and for filming walking activities. Return the video with your completed patient information form to the address provided.* PATIENT INFORMATION Name: Address: City State Zipcode Phone: Gender: ( ) Male Female Date of Birth: Age I am interested in: (Check one) Arm and Hand Program Leg Program Both Last Grade Completed Occupation CAREGIVER INFORMATION* *caregiver other than a physician (could include a family member, friend, nurse, etc.) Name: Address: Phone: ( ) Relationship to Patient: Additional Contact Person: Phone: ( ) TYPE OF INJURY Date of Injury: Side of Body Most Affected: Stroke Dominant Hand Prior to the event: Left Right Traumatic Brain Injury I am currently receiving : Broken Hip Spinal Cord Injury Other PT OT Speech I carry out a home exercise program days per week for mintues per day. Describe: WALKING INFORMATION Are you able to walk? Do you use a wheelchair? If you are able to walk, do you use a walker? If you are able to walk, do you use a cane? If you are able to walk, do you use a brace? About how far can you walk at one time? Do you walk at least 25 feet, 5 times a day? About how many times each day do you walk?

3 TAUB THERAPY CLINIC Constraint Induced Movement Therapy AFFECTED HAND AND ARM INFORMATION Please answer questions 1 through 3 with the weaker forearm resting on the arm of a chair, with the wrist bent downward and the hand hanging loosely over the front edge of the armrest. 1. Can you bend your wrist back without lifting your forearm? 2. Can you open your hand? 3. Can you move your thumb away from the palm of your hand? For questions 4 through 7, your arm does not need to be in any special position. 4. Can you straighten your elbow? 6. Can you raise your arm at the shoulder? 7. Can you pick up a tennis ball and release it? 5. Can you touch your chin with your more-affected hand and return it to your lap? 8. Can you pick up a washcloth and release it? MEDICATION INFORMATION Please list all of your current medications and their intents. MEDICATION INTENT Do you take oral medications for spasticity? If yes, are you on a steady dose? What medication? Have you received injections (Botox) to decrease your spasticity? If yes, when were your last injections & how did your body respond to these injections? Did you see benefit from these injections? Please describe. HEALTH INFORMATION Please mark if you have a history of any of the following conditions. Heart Disease Cancer Hypertension Depression Pulmonary Disease Diabetes Thyroid Gland Disease Head Injury or Surgery Seizures Expressive Aphasia Allergies, Asthma Receptive Aphasia Anemia or Other Blood Problems Other IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE EXPLAIN. PLEASE LIST THE NAME/CONTACT INFORMATION OF ANY PHYSICIAN AND/OR THERAPISTS YOU ARE SEEING. Please return this completed information form to: UAB Taub Therapy Clinic Spain Rehabilitation Center - R th Avenue South Birmingham, AL Clinic taubclinic@uabmc.edu

4 TAUB THERAPY CLINIC Constraint Induced Movement Therapy PAIN SCREEN 1. Do you have pain that interferes with your life or activities? If so, which word or words best describe the pattern of your pain? Continuous, Periodic, Momentary. 2. What kinds of things relieve your pain? 3. What kinds of things increase your pain? 4. How strong is your pain? People agree that the following 5 words represent pain of increasing intensity. They are: 1-mild 2-discomforting 3-distressing 4-horrible 5-excruciating Please answer each of the following questions using the most appropriate word from the above selection. 1) Which word describes your pain right now? 2) Which word describes it as its worst? 3) Which word describes it when it is at its least? YOUR GOALS FOR PARTICIPATION Please list any goals you would like to accomplish during your treatment. Please be specific with your answers. For example: " I would like to work outdoors without my cane."" I would like to be able to use utensils to cut food." Please return this completed information form to: UAB Taub Therapy Clinic Spain Rehabilitation Center - R th Avenue South Birmingham, AL Clinic taubclinic@uabmc.edu

5 VIDEO INSTRUCTIONS Dear Interested Patient: In addition to sending your patient information form, we also ask you send in a video. The video will allow our staff to evaluate your current movement ability with your involved upper extremity and your ability to walk. Listed below are the items to be included in the video. If you are interested in both the upper and lower extremity programs, please include the movement of your involved upper extremity, as well as video of yourself walking. UPPER EXTREMITY If you have difficulty performing the requested movement or are unable to complete the task as requested, please film your attempts of the movement or do as much of the task as possible. Perform or attempt each individual movement three times within one minute unless otherwise specified. Camera angle: Items 1-6 position the camera opposite your affected side. o Items 1-5 zoom in on your hand movement. Items 7-10 position in the camera in front of you. o Items 7-10 zoom out to include your entire upper body during these tasks. Arm and Hand position Items 1-2 should be performed while seated in a chair with armrests: o Place your involved forearm on the armrest of a chair o Wrist bent downward and your hand hanging loosely over the front edge of the armrest. 1) Bend your wrist back without lifting your forearm from the armrest. 2) Open and close your hand as if making a fist Revised: 1/23/14

6 Items 3-6 should be performed while seated, with your involved forearm and hand should be resting on a table: 3) Move your thumb away from the palm of your hand. 4) Pick up a tennis ball from the table and release it. 5) Pick up a washcloth from the table and release it. 6) Place your hand on the table in front of you by moving it from your lap without assistance. Items 7-10 may be performed in sitting or standing: 7) Bend and straighten your elbow as far as you can. 8) Touch your chin with your hand and return it to your lap. 9) Keeping your elbow as straight as possible, raise your arm in front of you as high as you can. 10) With your arm at your side, lift your arm away from your body as far as you can (similar to lifting arm overhead during a jumping jack). LOWER EXTREMITY Please include a video of yourself walking at least 25 feet. If you require assistance of another person to walk, use a brace, or walk with an assistive device please include this in the video. 1) Include camera views of yourself walk from the following views: a. Front view b. Rear view c. Side view 2) Include video of walking to a chair, sitting down, and then standing back up from the chair. Please mail your video to the following address: Taub Therapy Clinic Spain Rehabilitation Center Room th Avenue South Birmingham, AL Please send us a DVD, attach video files to an , or upload videos to Snapfish at Should you send videos by , send them to the clinic s address at taubclinic@uabmc.edu Should you upload videos to Snapfish, please invite the Taub Clinic at our address, to view the videos. Revised: 1/23/14

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